Provider Demographics
NPI:1063566503
Name:CHERRY, CHARLES ROBERT JR (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:CHERRY
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17009 FREEDOM WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853
Mailing Address - Country:US
Mailing Address - Phone:301-774-6713
Mailing Address - Fax:
Practice Address - Street 1:SUITE 128 18111 PRINCE PHILIP DR
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832
Practice Address - Country:US
Practice Address - Phone:301-774-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00629103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
4899OtherCAREFIRST BLUE CROSS
091226OtherVALUE OPTIONS
4899OtherCAREFIRST BLUE CROSS